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Wise et al.

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trials demonstrated clinical benefit of probiotics, with improvement in TNSS (standardized mean difference [SMD] −1.23, p < 0.001), TOSS (SMD −1.84, p < 0.001), total QOL (SMD −1.84, p < 0.001), nasal QOL (SMD −2.30, p = 0.006), and ocular QOL (SMD −3.11, p = 0.005). Subgroup analysis demonstrated improvement in clinical parameters for SAR and PAR. Th1:Th2 ratio was improved (SMD −0.78, p = 0.045) in the probiotic group, with no difference in tIgE, sIgE, or eosinophil count. Zajac et al. 1420 published a systematic review and meta-analysis of 21 double-blind RCTs and 2 randomized crossover studies comprising 1919 adult and pediatric patients with SAR or PAR treated with 3 weeks to 12 months of probiotic vs placebo. A total of 26 level 1b studies analyzed by Guvenc et al. 1421 and Zajac et al. 1420 are included in Table IX.B.9. Zajac et al. 1420 limited outcomes measures to validated QOL or symptom scores and immunologic variables; 17 studies demonstrated clinical benefit of probiotics in AR. Meta analysis demonstrated improvement in RQLQ global score (SMD −2.23, p = 0.02) and RQLQ nasal symptom score (SMD −1.21, p < 0.00001). No effect was found for RTSS, tIgE, or sIgE. The preponderance of data from meta-analyses and double-blind RCTs suggests a beneficial effect for probiotics in the treatment of SAR and PAR in both adults and children, but interpretation is limited by the heterogeneity of age and diagnosis, interventions, and outcomes included in the studies. Probiotics varied in dose, were delivered via milk, yogurt, powder, or capsules, and included a number of diverse strains: 19 studies employed Lactobacillus species 1422-1440 ; 6 studies Bifidobacterium 1061,1433,1437,1441-1443 ; and 1 study each Tetragenococcus halophilus , 1444 Escherichia coli , 1445 and Bacillus clausii . 1446 • Aggregate Grade of Evidence: A (Level 1a: 2 studies; Level 1b: 26 studies; Table IX.B.9). • Benefit: Improved nasal/ocular symptoms or QOL in most studies. Possible improvement in immunologic parameters (Th1:Th2 ratio). • Harm: Low. • Benefits-Harm Assessment: Balance of benefit and harm. • Value Judgments: Minimal harm associated with probiotics, but heterogeneity across studies makes magnitude of benefit difficult to quantify. Variation in organism and dosing across trials prevents specific recommendation for treatment. • Policy Level: Option. • Intervention: Consider adjuvant use of probiotics for patients with symptomatic SAR and PAR. IX.B.10. Combination therapy IX.B.10.a Oral antihistamine and oral decongestant.: Oral antihistamines function as reversible competitive antagonists of the histaminic H 1 receptor and prevent the binding of histamine to its receptors. Oral decongestants, such as pseudoephedrine and phenylephrine,

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.